Provider Demographics
NPI:1437766060
Name:AFINIA DENTAL-KILLGORE FAIRFIELD INC
Entity Type:Organization
Organization Name:AFINIA DENTAL-KILLGORE FAIRFIELD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:KINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-746-8228
Mailing Address - Street 1:3174 MACK RD STE 5
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5369
Mailing Address - Country:US
Mailing Address - Phone:513-874-8636
Mailing Address - Fax:513-874-5227
Practice Address - Street 1:3174 MACK RD STE 5
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5369
Practice Address - Country:US
Practice Address - Phone:513-874-8636
Practice Address - Fax:513-874-5227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30-022880OtherLICENSE
OH1528078227OtherNPI